Background: Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility. Method: A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*. Results: We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use. Conclusions: Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Background People living with dementia vary in awareness of their abilities. We explored awareness of the condition and diagnosis in people with mild-to-moderate dementia, and how this relates to quality of life, well-being, life satisfaction, and caregiver stress. Methods This study was a cross-sectional exploratory analysis of data from the IDEAL cohort, which recruited people with dementia living at home and available caregivers from 29 research sites in Great Britain. Our study included 917 people with mild-to-moderate dementia and 755 carers. Low and high awareness groups were derived from self-reported responses to a dementia representation measure. Logistic regression was used to explore predictors of awareness of condition and diagnosis using demographic, cognitive, functional and psychological measures, and the relationship with quality of life, well-being and life satisfaction (‘living well’), and caregiver stress. Results There were 83 people with low awareness of their condition. The remaining 834 people showed some awareness and 103 of these had high awareness of their condition and diagnosis. Psychosocial factors were stronger predictors of awareness than cognitive and functional ability. Those with higher awareness reported lower mood, and lower scores on indices of living well as well as lower optimism, self-efficacy and self-esteem. Low awareness was more likely in those aged 80y and above, and living in more socially deprived areas. No relationship was seen between caregiver stress and awareness. Conclusions Awareness of the condition and diagnosis varies in people with mild-to-moderate dementia and is relevant to the capability to live well. Awareness should be considered in person-centered clinical care.

<b><i>Introduction:</i></b> Discrepancy scores reflecting the difference between parallel ratings made by people living with dementia (PwD) in the mild-to-moderate stages and by their informants provide a way to investigate awareness of functional ability in relation to activities of daily living (ADL). <b><i>Methods:</i></b> Two measures of ADL (Functional Activities Questionnaire; Dependence Scale) were completed by 1,227 PwD and their informants in the IDEAL cohort study baseline assessment. Self-rated and informant-rated scores were used to calculate discrepancies, which were used as an indicator of awareness of functional ability. Smaller discrepancy scores were considered to reflect greater awareness on the part of PwD. PwD completed questionnaires on depression, personality, comorbidities, neuropsychiatric symptoms, and completed a measure of cognition. Informants provided ratings of stress. Univariable and multiple regressions were used to investigate factors related to ADL discrepancy. <b><i>Results:</i></b> A similar pattern of associations were found for both ADL discrepancy scores. Smaller discrepancy scores were associated with higher levels of depression, higher neuroticism, fewer neuropsychiatric symptoms, higher comorbidity, lower carer stress, and receipt of less than 1 hour of care per day from the informant. <b><i>Discussion/Conclusion:</i></b> There was a clear pattern of factors that were associated with greater awareness for both measures of functional ability. These factors associated with smaller discrepancy scores could be used to identify PwD who might benefit from targeted interventions to support their independence.

Objectives Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post‐diagnostic support. Methods Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community‐dwelling people with mild‐to‐moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case‐matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness. Results At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case‐matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co‐morbidities. Conclusions Self‐reported awareness of difficulties can change and may increase over time in people with mild‐to‐moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease‐related symptom, and highlights the complex, individual and dynamic nature of awareness.

Background People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person’s awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods. Method We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia (“dement*” or “Alzheimer*” or “Pick’s disease”) and “awareness”, “unawareness”, “anosognosia”, “insight”, “denial”, “metacognit*” or “discrepanc*” identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified. Discussion This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted. Electronic supplementary material The online version of this article (10.1186/s13643-019-1078-5) contains supplementary material, which is available to authorized users.

Background: People with dementia differ in degree of awareness of difficulties.Awareness can influence well-being, communication and relationships, and impact on personal safety and decision-making in everyday and clinical situations. Evaluating awareness could facilitate person-centered care. A scoping review identified the lack of a brief, multidimensional clinical tool. We aimed to develop and test a new awareness interview for clinical use.Method: Measure development was informed by scoping review findings, available evidence about awareness phenomena in dementia, and considerations of suitability for remote as well as in-person administration. Some items were drawn from existing validated measures, covering awareness of functional ability, memory, and socio-emotional functioning, and new items were developed to assess awareness of medication management and mobility, providing a profile of awareness across these domains. Scoring was based on calculation of discrepancies between selfrating and either informant ratings or objective memory task performance, as well as self-reported acknowledgement of specific symptoms. The interview was tested for feasibility and acceptability in a remotely-administered pilot study. The interview was administered to 31 community-dwelling people with mild-to-moderate dementia recruited in England in 2020-2021, via telephone or Zoom video-call. A caregiver, acting as an informant, completed a corresponding questionnaire in advance. Cognitive ability of the participant with dementia was assessed with the Montreal Cognitive Assessment-5 minute protocol (MoCA-5 min). Structured and open-ended feedback was obtained from participants and caregivers Result:The interview was completed by 29 participants with MoCA-5 min scores ranging from 9.5 to 29.Two participants with lower MoCA-5 min scores were unable to complete the interview. Remote administration was straightforward with few challenges, taking on average under 11 minutes. Awareness profiles showed a spectrum of awareness across domains. Feedback indicated that interview questions were acceptable and understandable, but certain aspects, such as the memory task, could be somewhat upsetting as they highlighted current difficulties.

Background: Although awareness is known to vary in people with dementia, little is known about longitudinal trajectories of awareness of condition in people with mildto-moderate dementia. Exploring this could help understand the concepts around awareness, and reasons for apparent impaired awareness, relevant to person-centered care. Method:We used longitudinal data from the IDEAL programme for 917 communitydwelling people diagnosed with mild-to-moderate dementia. Using a validated checklist, we assessed awareness of personal difficulties associated with dementia at three timepoints over two years. Changes in awareness from baseline were examined. Focusing on people with low awareness at baseline, we used case-matching to compare characteristics between people who gained awareness over time, and those who continued with low awareness.Result: At baseline, 83 people showed low awareness of personal dementia-related difficulties. Following up this group, after attrition we examined data for 49 people at T2 and 25 people at T3. Most people remaining in the study had gained awareness at T2 and T3. Gains were seen up to four or more years after diagnosis. Five people continued to deny any of the common difficulties associated with dementia at all timepoints. These five reported slightly more comorbid conditions than matched cases. Few other distinguishing features were evident but in comparison, the people who came to acknowledge difficulties showed greater deterioration in cognitive and functional ability by T3. Conclusion:Over time, self-reported awareness of dementia-related difficulties can change in people with mild-to-moderate dementia. Awareness gains, seen in most people remaining in the study at T2 and T3, may have been prompted by deteriorating abilities. Reasons for ongoing low awareness were difficult to establish and may relate to individual circumstances including comorbidity. This highlights the individual complexity and dynamic nature of awareness in dementia and challenges the concept of impaired awareness as a fixed disease-related condition.